Puerperal Infection: Signs, Causes, And Treatment

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Puerperal infections, also called postpartum infections or Puerperal fever, include a wide range of infections that occur up to six weeks after childbirth. The most common postpartum infections are endometritis, urinary tract infection (UTI), wound infection, and mastitis. Puerperal infections may affect 5-24% of mothers and are common causes of prolonged hospitalization after childbirth. If left untreated, these infections can be life-threatening (1).

Read about the types, causes, symptoms, risk factors, complications, diagnosis, treatment, and prevention of puerperal infections.

What Are The Types Of Postpartum Infections?

Puerperal infections can be grouped into the following types (2):

1. Puerperal endometritis

Puerperal endometritis is the uterine wall (endometrium) infection in postpartum. The severity of endometritis may vary from mild to severe. If left unmanaged, the infection can spread to other layers of the uterus and extend beyond to the adnexa and the peritoneal cavity. Pelvic peritonitisⁱX A condition where the thin membrane in the abdomen that covers the organs is inflamed because of exposure to infected body fluids and peritonitis may become life threatening infections if neglected. Therefore, doctors may recommend preventive antibiotic treatment if a woman has a high risk for postpartum endometritis (3).

Quick fact

Endometritis occurs after childbirth due to the ascent of vaginal bacterial flora into the upper reproductive tract. The risk of infection is five to ten times higher after a c-section than after a vaginal delivery (5).

2. Surgical site infections

Surgical site infections (SSIs) are wound infections occurring on the incision site after c-section delivery. Bacteria from the skin infects the wound and interfere with healing and recovery. Superficial and deep incisional site infections may occur postpartum. Postcesarean wound infection affects nearly 2-7% of women who undergo c-section delivery (4).

Quick fact

Infections occurring within the first two days after surgery are most commonly caused by group A or B streptococci. Other possible infecting species include Ureaplasma urealyticum, Enterococcus faecalis, Escherichia coli, and Proteus mirabilis (5).

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3. Puerperal mastitis

Puerperal mastitis can be infective or non-infective. Incomplete emptying or poor breastfeeding techniques may cause milk stasis and non-infective mastitis. Cellulitis, intra-lobular tissue infection, abscess, and sepsis can be seen in infective mastitis.

Mastitis is common in the postpartum period, accounting for 12% of all postpartum infections. Most mothers develop puerperal mastitis within four weeks postpartum. Staphylococcus aureusⁱXBacteria commonly found in the environment and may cause boils, blisters, and inflammation of skin is the common organism causing infection, and this can enter the breasts through cracks in nipples or areola. Streptococci and E.coliⁱXA part of the gut microbiome, they are usually harmless but may contaminate food and water, causing diarrhea and fever may also cause mastitis (2).

Quick tip

You need not stop breastfeeding if you have developed mastitis as you will not pass the bacteria to your baby (9)

4. Urinary tract infections

Urinary tract infections (UTIs) such as acute cystitis (bladder infection) and pyelonephritis (kidney infection) may occur in postpartum. Nearly 8-12% of women reported having postpartum bacteriuria (bacteria in urine), and 25% of them developed dysuriaⁱXA condition that causes pain and burning during urination and other UTI symptoms.

Cesarean section delivery, operative vaginal delivery, bladder catheterization, etc., may increase the risk of UTIs after childbirth. However, many women tend to have asymptomatic pyuria (pus in urine) or bacteriuria postpartum. The morbidity of these conditions in the postpartum period is unknown (2).

5. Episiotomy or perineal infections

Episiotomy infections occur at the site of the episiotomy incision. There is a 0.1-2% chance of infections after episiotomy. The risk for developing infection increases with the increased degree of tear. Midline episiotomy and vaginal hematomas followed by vaginal birth can increase the risk of postpartum perineal infections (2).

6. Epidural abscess

Epidural abscess is the collection of pus in between the outer covering of the brain or spinal cord and skull or spine. This may occur due to infection followed by epidural anesthesia during labor and delivery. Skin organisms can enter during anesthesia if the sterility is not maintained. Most women develop epidural abscess within five days postpartum and have positive blood cultures. Some women may develop meningitisⁱXInflammation of the protective membranes and fluid that surround the brain and spinal cord , osteomyelitisⁱX An acute or chronic bone infection causing inflammation and swelling , or paraspinal muscle infection after epidurals. Fortunately, these are rare infections.

In addition, women are also vulnerable to severe influenza-related illness for the first two weeks postpartum. Therefore, health care providers encourage new mothers to seek early medical care and treatment for influenza-like illnesses and other infections in the early week of postpartum (2).

What Are The Risk Factors And Causes Of Puerperal Infections?

Trauma to the abdominal wall and genitourinary system (reproductive and urinary tract) is the major cause of postpartum infections. Physiologic or iatrogenic (caused by medical interventions) trauma during childbirth or abortion may cause bacterial contamination of sterile environments. Ascending bacterial infections can also occur when the bacteria from the skin move into the body.

The following risk factors may increase the likelihood of puerperal infections (5):

• Pre- or post-term labor
• Multiple internal exams (uterus exams)
• Thick meconium staining
• Prolonged labor

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• Prolonged rupture of membranes
• Internal uterine or fetal monitoring
• Operative vaginal delivery using vacuum or forceps
• Manual removal of the placenta
• Foley or urinary catheter use
• Postpartum hemorrhage
• Retained products of conception
• Sexually transmitted infections
• Bacterial vaginosis
• Group B streptococcus positive status
• High body mass index
• Diabetes mellitusⁱX A metabolic disorder where the body cannot use insulin properly
• HypertensionⁱXA condition where the blood pressure is higher than normal, increasing the risk of strokes and heart ailments
• Advanced maternal age
• Immune compromise (weak immune system)

Overweight with advanced maternal age is associated with a higher risk of postpartum infections. This can be due to the increased risk of pregnancy and delivery-related complications.

What Are The Signs And Symptoms Of A Postpartum Infection?

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Signs and symptoms of puerperal infections may vary depending on the type and severity. However, fever and pain can be seen in most postpartum infections.

Common signs and symptoms of puerperal infections may include (2):

• Fever
• Uterine tenderness
• Vaginal bleeding
• Foul-smelling lochia
• Mild or severe abdominal pain
• Erythema (redness), warmness, swelling, and pain on the incision site
• Purulent discharge from the wound
• Headache
• Focal neurologic signs

It is recommended to seek a doctor’s advice if you notice any signs and symptoms of infection postpartum.

Can Puerperal Infections Cause Complications?

The following complications may occur if the puerperal infections are not treated appropriately (2):

• Sepsis is a medical emergency when the body shows an extreme response to an infection.
• Bacteremia is the presence of bacteria in the blood. This can be asymptomatic in most cases.
• Shock or septic shock is when the blood flow is diminished due to hypotension (low blood pressure).
• Septic pelvic thrombophlebitis (SPT), also called suppurative pelvic thrombophlebitis, is infection and damage of the ovarian veins and blood clot formation (thrombogenesis). This may occur if the endometritisⁱXA condition that causes inflammation in the lining of the uterus Mastitis: Breast inflammation causing pain and swelling or other pelvic infection is not treated appropriately.
• Necrotizing fasciitis (NF) is also known as a flesh-eating disease that causes the death of body tissue. This may occur in intense and severe infections (fulminant infections)
• Abscess (collection of pus) and peritonitis (inflammation of the peritoneum) are complications progressing beyond the uterus.

The symptoms of shock, systemic illness, and severe abdominal pain may indicate complications such as toxic shock syndrome or necrotizing fasciitis. Severe symptoms require immediate medical care.

Can Puerperal Infections Be Prevented?

The healthcare providers practice the following strategies to avoid the risk of spreading infections to the mother in the hospital settings (6):

• Maintain hand hygiene

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• Change scrub clothes
• Isolate infected persons
• Limit the staff contact
• Administration of prophylactic antibiotics
• Use of sterilized medical device properly

Doctors may also recommend the following to help prevent postpartum infections (7):

• Practice frequent hand washing
• Avoid shaving before the delivery
• Avoid the use of public pools, saunas, and tubs after delivery
• Use sanitary pads instead of tampons and change the pads on time
• Avoid sexual intercourse or inserting anything into the vagina until the vaginal bleeding stops postpartum
• Avoid the use of vaginal douches
• Do not hold urine
• Drink plenty of water
• Avoid wiping from back to front after using toilets

How Is The Puerperal Infection Diagnosed?

History of birth events, risk factors, presenting symptoms, and the physical examination may help the healthcare provider diagnose puerperal infections in many cases. A blood and urine test is usually ordered to look for any changes. Leukocyte count (white blood cells) can be high in several bacterial infections. However, this may not be specific during pregnancy and postpartum.

Urine or vaginal swab culture may help identify the causative organism. Obstetricians may form ultrasound imaging if it is required. Blood culture of repeated bacterial specimens and measures of serum lactate levels are done in puerperal sepsis.

What Is Postpartum Sepsis?

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The World Health Organization (WHO) defines puerperal sepsis as the genital tract infection occurring at labor or within 42 days postpartum.

The following symptoms are seen in postpartum sepsis (8):

• Fever (pyrexia)
• Pelvic pain
• Delay in uterus size reduction (uterus involution)
• Foul-smelling vaginal discharge

If left unmanaged, puerperal sepsis may result in maternal death. WHO reports estimate that 15% of maternal death due to childbirth problems may occur due to puerperal sepsis.

How Are Postpartum Infections Treated?

Antibiotics are prescribed for puerperal infections. The treatment may begin with broad-spectrum antibiotics. Oral antibiotic therapy is suggested for mild infections, and specific antibiotics are given based on clinical presentation, post blood, and urine tests. Doctors may prescribe regimens including more than one antibiotic medication.

Some women with severe symptoms such as high fever may require hospital administration and intravenous antibiotic therapy until the fever subsides for 24 to 48 hours. Supportive care such as electrolytes and IV fluids are given if needed. Lactation-safe medications that do not affect the baby are given to breastfeeding mothers (2).

What Is The Outlook For Puerperal Infections?

The prognosis of postpartum infections is related to the severity of the infection. Nearly five to ten percent of women with puerperal infections experience consequences. Women with postpartum sepsis have 20%, and septic shock has a 40% mortality rate. However, identifying and treating infections in the initial stages can help prevent life-threatening complications in the postpartum period (5).

Infographic: Different Types Of Puerperal Infections

The phase after delivery ensues several events, such as having the responsibility of caring for the newborn, recovering from the birthing process, and getting back into the pre-pregnancy state. Additionally, you also have to be aware of any potential puerperal or postpartum infections that may occur. Check out the infographic below to learn about various types of puerperal infections.

Illustration: Momjunction Design Team

Image: Dall·E/MomJunction Design Team

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Dr. Ben Abbes Taarji HichamMD

Dr. Ben Abbes Taarji Hicham is a practicing obstetrician and gynecologist with around 20 years of experience in the field. Having worked in various Moroccan hospitals, he currently runs a private practice. Dr. Hicham specializes in rejuvenation and cosmetic gynecology, medically assisted reproduction, breast and gynecological cancers, HPV diseases, hysteroscopy and laparoscopy, and hormonal disorders.more

Dr Bisny T. JosephMedical Doctor

Dr. Bisny T. Joseph is a Georgian Board-certified physician. She has completed her professional graduate degree as a medical doctor from Tbilisi State Medical University, Georgia. She has around 5 years of experience in various sectors of medical affairs as a physician, medical reviewer, medical writer, health coach, and Q&A expert. Her interest in digital medical education and patient education...more

Rebecca MalachiBSc

Rebecca is a pregnancy writer and editor with a passion for delivering research-based and engaging content in areas of fertility, pregnancy, birth, and post-pregnancy. She did her graduation in Biotechnology and Genetics from Loyola Academy, Osmania University and obtained a certification in ‘Nutrition and Lifestyle in Pregnancy’ from Ludwig Maximilian University of Munich (LMU). She has been into health and...more

Reshmi DasMSc

Reshmi Das has over four years of experience as a clinical coordinator, medical content writer and medical conference coordinator. Her continuous interest in medical journals and writing makes her write well-researched articles for MomJunction. She writes health and wellness articles for children and pregnant and lactating women. Reshmi has completed her post graduation in Biotechnology from MITS School of Biotechnology,...more